Speech by Mr Ong Ye Kung, Minister for Health At the National Kidney Foundation 55th Anniversary Celebration, 25 April 2024 At Nkf Centre

Mr Arthur Lang, Chairman, National Kidney Foundation

Mr Tim Oei, CEO, NKF

NKF Board Members, present as well as past

Mr & Mrs Arnold Khoo

Beneficiaries, donors, volunteers, partners, staff, ladies and gentlemen

1. It is my great pleasure to join you today to celebrate this milestone 55th anniversary.

Achievements and Advancements Over the Years

2. NKF was founded by the late Professor Khoo Oon Teik in 1969, to provide affordable dialysis treatment for patients with kidney failure. Today, we are very happy to be joined by his son and daughter-in-law, Mr and Mrs Arnold Khoo.

3. For over 55 years, NKF has transformed dialysis care in Singapore. Now, beyond dialysis treatment, NKF is now delivering holistic care for its patients, including kidney disease prevention, emotional and psychosocial support for patients and their caregivers, and programmes to help patients re-integrate into society and lead fulfilling lives.

4. However, we face a significant challenge ahead. Each day, six new patients are diagnosed with kidney failure in Singapore. The total number of kidney failure patients is rising. Ten years ago, it was 5,500. Today, it is 8,800.

5. What is driving this? The major culprits are diabetes and hypertension. These are precursors to kidney failure. As our population ages, the prevalence of these chronic diseases tend to increase. If we can somehow manage these chronic diseases, we can somewhat flatten the curve. Take Singapore residents aged 65 to 79 for example. In 2010, the prevalence of hypertension was about 65% amongst this group, so two in three have hypertension. In the latest National Population Health Survey, it has gone up to over 71%. The prevalence of diabetes is more stable for this age group, hovering around 20% to 25% since 2010, and even detect a slight downtrend, hopefully it becomes a trend in recent years. The war on diabetes has some impact on this. But we can certainly do a lot better.

6. To cope with the higher patient load, NKF has expanded its operations to 41 dialysis centres island-wide and will be opening more centres over the next few years. At the same time, the Government is providing more resources and support to providers to expand your operations.

7. It is not in a good situation. This is one part of operations that you don't wish to expand but it is expanding. More and more healthy people are getting onto the chronic disease travellator. Some can walk against the direction of the travellator and stay put. But many are carried further down the path of disease progression, the onset of kidney diseases, and eventually kidney failure, needing dialysis or transplant.

8. Our fight against kidney failure involves intervening at every stage of this deadly travellator. Let me talk about the three stages in reverse order - treating kidney failure, managing diabetes and hypertension, and preventing the onset of chronic diseases in the first place.

Support for Kidney Failure Patients

9. For patients who have gone far along the travellator, and whose kidneys have failed, they will need dialysis.

10. The Ministry of Health (MOH) has been working with public hospitals and social service organisations to recommend Peritoneal Dialysis (PD) as the preferred dialysis option, unless they are medically unsuitable. This is because PD can be done at the patient's home, providing greater convenience and freedom to lead a more normal life, and with outcomes comparable to Haemodialysis.

11. To this end, MOH launched the National PD Home Support Programme two years ago. To date, about 300 patients are enrolled in the programme, with good clinical outcomes. Patients have also provided feedback that they are now more confident in performing PD independently. It is not easy to start PD but for those who have started, they are now more confident that they can perform this at home. We will continue to work with public healthcare institutions and service providers such as NKF to expand the enrolment of the programme. This programme is no longer a pilot; it is a mainstream programme, and we just need to get more people onto it.

12. A serious challenge is the rising cost of kidney dialysis. Treatment at NKF costs around $30,000 a year - not easily affordable by most Singaporeans. The Government therefore supports patients by subsidising dialysis fees. This is not enough, so patients can also claim medical insurance, namely under MediShield Life, our national health insurance policy, for their kidney dialysis treatment. As for the remaining expenses, they can use their MediSave to pay.

13. But there are many patients who may not have enough MediSave, or need to preserve their MediSave for other medical expenses later on in life. Hence, NKF, through your own effort, is also raising charity funds to help these patients.

14. To illustrate what I just described earlier in numbers - in FY2023, NKF spent around $143 million to support over 5,500 patients. $60 million, or over 40%, comes from government subsidies. Around $40 million, or 30%, comes from MediShield Life and MediSave. $27 million, or 20%, are charity dollars raised by NKF, and the remainder is largely out-of-pocket expenses by patients. The great majority of NKF patients, because of subsidies, MediSave, MediShield Life and NKF's charity, pay no more than $50 per month. In fact, four in ten do not pay anything at all. So from a bill of $30,000 a year, four in ten do not pay anything, and most pay about $50 a month. The help is tremendous.

15. However, dialysis providers are facing rising operating costs and growing demand. The number of patients is also rising. As hard as they try, the charity dollars raised by community partners like NKF will not be able to keep up with the rise in costs. If we don't do anything, eventually patients will have to pay more.

16. To continue to keep dialysis affordable, other sources of funding will need to help pick up the tab of rising costs. There are only three other sources.

17. The first is subsidy. Government subsidies will increase in tandem with the rise in kidney dialysis expenditure. Later this year, the Government will adjust the income thresholds for subsidies and grants for healthcare and social support services and this will extend to NKF, so there will be more subsidy coming your way for kidney dialysis patients. The second is MediSave. MOH is also reviewing MediSave limits for medical treatments like dialysis, so you can use more of your MediSave for dialysis.

18. The final source is MediShield Life. On this front, MOH is working with the MediShield Life Council to review and increase the MediShield Life claim limits for dialysis treatments.

19. All these changes will help dialysis patients offset the rise in treatment costs. Further, it relieves the immense pressure for organisations like NKF to have to raise more and more charity donations, which is not sustainable. But higher claims will push up MediShield Life premiums. As I have said in Parliament earlier this year, MOH will do our best to ensure that as far as possible, the additional premiums can be paid through MediSave by members.

Reducing Kidney Failure Cases

20. For patients who just got onto the travellator, we need to help them walk against the direction of the travellator. This is so that they at least stay put on the same spot, or at least slow down their progression to kidney failure.

21. Today, our major tool is Healthier SG. I think if we are on this flight, you have two big engines, one of which is Healthier SG. Under Healthier SG, individuals with diabetes and hypertension are encouraged to follow up with their family doctor to optimise control of their condition and undergo regular screening tests to detect kidney disease early.

22. This can potentially be a big gamechanger for NKF for kidney disease prevention because before Healthier SG, we had not mobilised our entire network of General Practitioners (GPs) to help manage such chronic diseases. Today, we have them mobilised. The government is rewarding them and paying them a fee to do so. We have a Health Plan for everyone enrolled in Healthier SG, which includes regular screening. If you don't go for regular screening, your Healthier SG doctor is supposed to call you to remind and nag you. I hear of many stories of friends and colleagues, whose doctors are calling them, and they are going for their Healthier SG check-ups.

23. For example, those with Type 1 Diabetes Mellitus (DM) have high blood glucose because their body inherently does not produce enough insulin. The mainstay of treatment today for this condition is insulin therapy. However, one of the risks of insulin therapy is that blood glucose can become very low, also known as hypoglycaemia or "hypo". It can happen fast and can be dangerous, especially when it occurs during sleep. Therefore, those with Type 1 DM have to regularly self-monitor their blood glucose levels, usually with a finger-prick and a glucose meter.

24. To help them, we will make better use of Continuous Glucose Monitoring (CGM) devices. CGM is a wearable technology, usually a patch to wear on the arm, that monitors glucose levels and trends throughout the day, with readings transmitted wirelessly to a smartphone or a reader device. From 1 May 2024, MOH will extend subsidies to CGM for eligible adults and children living with Type 1 DM and who are receiving care in public healthcare institutions.

25. Over the years, there have been some requests for CGM to be more broadly subsidised for diabetes patients. But the cost of CGM has not been cheap, so if we want to use it amongst the population for preventive care, we have to make sure it is cost-effective. Our studies showed that while CGM works for some patients, it does not for many others. Ultimately, it depends on the patients' motivation and behaviour.

26. That said, the situation is evolving. We are going to start to use CGM and subsidise it for Type 1 diabetes. We will continue to study the situation. The good news is there are now more CGM products in the market, providing much needed competition. We will start the first step as I mentioned, to subsidise CGM for Type 1 DM patients, monitor the situation closely and study its cost effectiveness better.

Healthier Lifestyles

27. The larger effort has to be to promote healthier lifestyles. This will extend to those who are not yet on the travellator, and we should prevent them from ever setting foot on it. This aligns with the broader goals of Healthier SG.

28. We are also doing more to encourage individuals to adopt healthier diets, especially to regulate the intake of sugar, which is associated with the development of Type 2 diabetes. Our efforts so far have been effective.

29. There are two big engines for this flight we are on - one is Heathier SG and the other engine is health promotion. Surprisingly, our health promotion has been unexpectedly successful in cutting down sugar intake. We considered whether to tax sugar or label high sugar drinks. We decided, fortunately, not to tax. To tax sugar is difficult. You can tax sugar in drinks but how do you tax sugar cane stalls? We decided to label and asked ourselves what the main source of sugar intake by Singaporeans is. It turns out packaged drinks account for about 40 to 50% of our sugar intake. So we decided to label packaged drinks. The Health Promotion Board (HPB) came up with a very effective labelling method, which is Nutri-Grade. I don't know if HPB thought about it but Singaporeans are naturally grade conscious. So gradually people avoided the Ds. Today it is very heartening when I see young teenagers buying bubble tea, and they say they don't want D.

30. I think we need to do more. Going forward, there will be more plans, not just to tackle sugar but to move on to sodium, found in salt. A diet high in sodium is a big risk factor for hypertension. HPB has a programme called Healthier Ingredient Development Scheme (HIDS) which has increased the availability and affordability of lower-sodium alternatives. Over 60% of wholesalers of salt are now supplying lower-sodium salt. HPB has a slogan, "Less Salt, More Taste". Put less salt in your food, and you taste more of it. Put more salt in your food, and all you taste is salt. It has gained some traction, with a growing number of industry players committed to this initiative. Tackle salt, tackle sugar, then we can tackle diabetes, hypertension, and we start to prevent the onset of kidney disease and kidney failure.

Closing

31. In closing, I want to thank and applaud the NKF for your commitment to kidney failure patients all these years. Throughout MOH, wherever I go in our public health institutions or community partners like NKF, one common characteristic cutting across all our healthcare providers, whether public, private or community, is your heart. Whatever you do here, you always do with your heart to help patients, to help people, to help Singaporeans and to help everyone under your charge.

32. Here in NKF, your patients particularly, have all displayed a strong spirit of resilience. It is not easy to go through dialysis. I hope all patients at NKF can be an ambassador against kidney failure. Be an ambassador for a healthier lifestyle, and affect and influence all those around you to lead healthier lives and have better kidneys.

33. Thank you to the care team, donors and volunteers. I wish NKF a happy 55th anniversary. Thank you.